Nursing Elites

1. A patient's nursing diagnosis is Insomnia. The desired outcome is: 'Patient will sleep for a minimum of 5 hours nightly by October 31.' On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?

• A. Consistently demonstrated
• B. Often demonstrated
• C. Sometimes demonstrated
• D. Never demonstrated

Correct answer: D

Rationale: The correct answer is 'Never demonstrated.' Despite the patient sleeping a total of 6 hours daily, it is not achieved in one uninterrupted session at night as per the desired outcome. The patient's habit of taking a 2-hour afternoon nap also affects the evaluation. Therefore, the outcome should be evaluated as 'Never demonstrated.' Choice A, 'Consistently demonstrated,' is incorrect because the desired outcome of sleeping for a minimum of 5 hours nightly in one session is not met. Choice B, 'Often demonstrated,' is incorrect as the patient's sleep pattern does not consistently align with the desired outcome. Choice C, 'Sometimes demonstrated,' is also incorrect as the patient's sleep pattern does not meet the specific criteria set in the desired outcome.

2. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

3. To which of the following do the CDC Standard precautions recommendations apply?

• A. Patients with diagnosed infections only
• B. Blood or body fluids with visible blood only
• C. All body fluids including sweat
• D. All patients receiving care in hospitals

Correct answer: D

Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.

4. Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:

• A. Institute complete bed rest for the client
• B. Assess uterine tone to determine condition
• C. Perform a vaginal exam to assess cervical dilation
• D. Measure and record blood loss each shift

Correct answer: C

Rationale: A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.

5. A patient is in the office for a cyst removal and is very anxious about the procedure. Which of the following descriptions of his respirations would be expected?

• A. Bradypnea
• B. Orthopnea
• C. Tachypnea
• D. Dyspnea

Correct answer: C

Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (Choice A) is slow breathing, which is not expected in an anxious patient. Orthopnea (Choice B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (Choice D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure. Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.

Similar Questions